When did you complete the IEP Application Form? ---JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember---12345678910111213141516171819202122232425262728293031---20182019
Name on Card:
Expiration Date: ---01 January02 February03 March04 April05 May06 June07 July08 August09 September10 October11 November12 December---20172018201920202021202220232024202520262027202820292030
Billing Zip Code (Postal Code):
Visa or Mastercard? VisaMastercard
Fee to Pay: ---$125.00 Application FeeHousing Fee: see notesOther: see notes
By clicking "Submit" below, I agree that I am the person whose name appears on the credit card information above, and that I agree to pay thenon-refundable IEP Application Fee (or other charge as specified).
Note: If the information on this form does not match the information on the IEP Application Form, the Application Fee will not be processed.